Management
Possible therapies for retroversion or incarceration include the following:
Bladder drainage by indwelling catheter
Patient positioning exercises (eg, intermittent knee-chest or all-fours positioning, sleeping prone)
Manipulation of the uterus into its usual anatomic position, with or without tocolysis or anesthesia
Colonoscopic manipulation of the uterine fundus under anesthesia
Surgical exploration and replacement (almost never indicated)
Specialized and rarely attempted techniques of replacement (eg, employment of a mercury-filled Voorhees bag in the vagina, amniocentesis with manipulation)
The best treatment for symptomatic midtrimester incarceration of a normal uterus is a trial of bladder decompression combined with a program of patient positioning. Such management relieves the majority of cases. Prior to attempting any uterine manipulations, an indwelling catheter is inserted for 24-48 hours. If a urinary tract infection is present, appropriate treatment should also be initiated at this time. During this interval of bladder drainage, the patient is instructed to perform repositioning exercises on a frequent basis. These consist of modified all-fours or knee-chest positioning several times a day for intervals of 5-15 minutes. She is also instructed to sleep in the prone position. Spontaneous repositioning often occurs with these steps alone.
If these outpatient maneuvers prove unsuccessful, manual uterine replacement is attempted. Following an informed consent and ultrasound examination, a tocolytic such as terbutaline (0.250 mg) is electively administered 15-20 minutes before the attempted reversion. Note that there are no data concerning the efficacy of tocolytic therapy for this indication and its use is elective.
Before the procedure begins, an attendant is recruited to be present to support and encourage the patient and to help prevent a fall. In the replacement procedure (see Image 2), the anterior lip of the cervix is first grasped with a long Allis or other atraumatic clamp. The patient is then placed in the knee-chest or all-fours position. Pressure is applied to the incarcerated fundus by the surgeon's finger inserted into the vagina or rectum. At the same time, gentle but constant traction is applied to the cervix. The uterus then slowly rotates into the normal position. In theory, passing the fundus to one side or the other of the sacral promontory where there is more room is probably best. In the author's experience, such refinements in technique are nearly impossible to achieve.
These maneuvers usually prove successful. This repositioning maneuver should neither be painful for the gravida nor difficult for the accoucheur. Only mild-to-moderate force is appropriate for replacement. Excessive force jeopardizes patient compliance, risks a cervical injury from the cervical grasping instrument, or in theory, could possibly damage the fetus by distorting the uterus or obstructing uterine blood flow.
In unusual instances, when both bladder drainage with repositioning and a trial of gentle manipulation fail to replace the uterus, other methods need to be considered. The literature includes reports of a number of other techniques for uterine repositioning. These include unusual maneuvers such as the placement of a mercury-filled Voorhees bag in the vagina, along with other more complex repositioning methods. These are of historical interest only.
If bladder drainage and maternal repositioning are unsuccessful, maternal relaxation by the use of anesthesia combined with a tocolytic is a reasonable next step. To perform the procedure for uterine replacement under anesthesia, an epidural is administered. A general anesthetic using a uterine-relaxing agent could be given, avoiding the use of a separate tocolytic drug. This approach is not favored by this reviewer.
The anterior lip of the cervix is then grasped with a long Allis or other atraumatic clamp. The gravida is positioned in lateral recumbency. Next, intravenous nitroglycerin (0.15-0.5 mg IV titrated to effect) or a parenteral beta-mimetic (eg, terbutaline 0.15-0.25 mg IV/SC) are electively administered. After an interval for the tocolytic to take effect, cervical traction is combined with rectal pressure against the fundus in the same manner as previously described. Another technique described utilizes a colonoscope to provide the upward force to dislodge the entrapped fundus. If real-time ultrasound guidance is available for these procedures, its use is prudent. Successful replacement is verified both by palpation and real-time ultrasound scanning.
When replacement is successful by any technique, the patient may be instructed to continue to sleep in the prone position, practice occasional knee-chest or all-fours positioning, or to use a pessary to keep the uterus correctly positioned. These manipulations are probably not necessary. Reincarceration does not occur during the same pregnancy once the uterus has been released by manipulation. No studies have been performed regarding either the efficacy or the necessity of any of these postreplacement manipulations.
Following any procedures to attempt uterine replacement, administration of Rh immune globulin is indicated in Rh-negative patients who are not isoimmunized. Prompt resolution of the acute symptoms should occur after replacement. With modern techniques of management, serious maternal problems due to retroversion or incarceration and consequential fetal complications should be rare. On the other hand, in rare cases of chronic uterine retroversion, ballooning out of the lateral uterine wall may permit the uterus to expand abdominally. This can progress even into the third trimester. In such cases, the correct diagnosis is only established when dystocia in labor ensues or markedly unusual findings are noted on pelvic examination. In these cases, a cesarean delivery is required.
In the midtrimester, spontaneous abortion is possible due to incarceration alone or may follow manual uterine replacement. The risk of such losses, although unknown, is believed to be low. When midtrimester repositioning maneuvering is performed, verifying the presence of a fetal heart sound and conducting as much of an anatomic survey as possible is prudent prior to attempting any manipulations. Postprocedure, repeat real-time ultrasound scanning should reveal normal fetal cardiac activity and motion.
Comments
In nonpregnant individuals, if symptoms occur from retroversion alone they usually are minimal. Pelvic pain and related symptoms are principally due to coincidental pathology. Evidence that retroversion alone is responsible for abortion or infertility is lacking. When these conditions are encountered, another etiology must be sought.
Appropriately, uterine suspension procedures have virtually disappeared from gynecologic surgery except for cases involving specific pathology when the suspension is perceived to help prevent the formation of new adhesions during healing. As an example, uterine suspension is frequently performed when retroversion is associated with endometriosis or tubal pregnancy or following microsurgical tubal reconstruction procedures for infertility. However, the presence of uterine retroversion alone in an asymptomatic patient is not an indication for a prophylactic uterine suspension or similar procedure.
Uterine suspension following lysis of adhesions for chronic pelvic pain in nonpregnant individuals with uterine retroversion does not invariably relieve symptoms. This is especially true when patients are monitored long term. Thus, conservatively and critically review data claiming to relieve or lessen abdominal-pelvic distress following any specific procedure or therapy to correct retroversion. Unfortunately, randomized trials are infrequent in evaluating the various surgical and medical therapies for chronic pelvic pain. The most consistent symptoms associated with retroversion or incarceration in pregnancy are problems with micturition. Classically, these difficulties begin in the second trimester. All pregnant women with developing urinary tract symptoms (paradoxically including both incontinence and the inability to void) should undergo pelvic examination prior to instituting invasive urologic studies.
Unusually, symptomatic retroversion with bladder outlet obstruction occurs in the puerperium, or even later. This is due to persisting uterine enlargement or subinvolution, flaccidity of the supporting tissues, and other unknown causes.
The paucity of data concerning the risks associated with retroversion or incarceration during pregnancy makes counseling difficult. Patients should be informed that both symptomatic incarceration and its relief carry some risk of pregnancy loss. As has been emphasized, in all cases it is best to precede any intervention, especially those involving uterine manipulations, by a real-time ultrasound examination. This is both to verify the original diagnosis and to confirm that an anatomically normal and living fetus is present. A repeat study after repositioning confirms the success of the procedure, verifies an active fetus and normal amniotic fluid, and reassures both the patient and practitioner.
In nonpregnant patients, the evaluation of chronic pelvic pain accompanying uterine retroversion includes the consideration of 2 indistinct and somewhat suspect syndrome complexes. These are the pelvic congestion and Allen-Masters syndromes (AMS). The AMS, originally described in 1955, has 3 elements: (1) a history of obstetric pelvic trauma, (2) uterine retroversion with a hypermobile cervix on physical examination, and (3) tear(s) in the posterior serosa and subperitoneal fascia of the broad ligament on visualization. In theory, repair of these tears accompanied by ancillary procedures such as utero-sacral ligament plication to return the uterus to the usual anterior position are curative. Symptoms attributed to AMS are multiple. These include chronic pelvic pain, dyspareunia, and various menstrual disturbances.
Evaluation and treatment consists of first establishing the diagnosis visually at laparotomy or laparoscopy. Subsequently, any peritoneal broad ligament defects are fulgurated or sutured. Other surgical procedures are frequently performed at the same time such as shortening of the uterosacral ligaments, resection or obliteration of the pouch of Douglas, or other similar operations to cause the uterus to retain anteflexion and to remain anteflexed. While AMS was originally described as secondary to obstetric injuries, a similar symptom complex has also been attributed to endometriosis independent of a history of obstetric trauma. AMS remains a diagnosis of exclusion, and the very existence of this syndrome is questioned.
Another possible diagnosis is the pelvic congestion syndrome (PCS) or Taylor syndrome. This condition is characterized by menometrorrhagia and symptoms of continuous pelvic pain. On examination the uterus is variably enlarged and soft and some degree of tenderness is present. The cervix may be patulous or cyanotic. Retroversion may or may not be present. These symptoms and observations are nonspecific and render this diagnostic entity also suspect. Treatment possibilities for PCS are usually similar to those for AMS.
Other rare conditions can mimic simple uterine retroversion or incarceration. In müllerian anomalies, a uterus didelphys or an unconnected rudimentary horn can become positioned in the lower pelvis, rotating or displacing normal structures anteriorly, thus presenting similarly to an incarceration. The exceedingly rare uterine sacculation or herniation could also be confusing because of the distortion of normal anatomy. Tumors arising in the adnexa or myometrium can fill the pelvis and press on the uterus anteriorly, rotating its position or distorting its shape. Again, this process might result in symptoms or physical examination findings similar to that of simple incarceration.
These unusual conditions mimicking retroversion or incarceration in early pregnancy are promptly excluded by a combination of history and findings on physical examination and real-time ultrasound scanning. In unusual cases, MRI can complement these investigations.
The rare instances of retroversion diagnosed after the second trimester or cases complicated by pelvic adhesions or due to permanent distortions in uterine shape by tumors or congenital anomalies are difficult to manage. These problems require individualized treatment. In most of these unusual or atypical cases, the correct diagnosis is often not made until the abdomen is opened for a cesarean delivery.
Multiple gestations, now commonly secondary to the use of assisted reproductive technologies, are a special case. In this setting, the uterus can incarcerate at earlier periods of gestation than when only a single fetus is present. This is presumably due simply to the increased uterine size. Thus, if characteristic symptoms occur in women with known multiple gestations—even when the pregnancy has not reached 12 weeks gestation—retroversion or incarceration should remain in the differential diagnosis. Of interest, the literature includes few cases of incarceration of the uterus in spontaneously occurring multiple gestations. It is not known whether the higher incidence of retroversion or incarceration in early multiple gestations is a new phenomenon related to some unrecognized effect of infertility treatment or if the past incidence of incarceration among those with similar pregnancies was understated due to a sampling or reporting error.